Should doctors recommend acupuncture for pain?

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The authors opposing acupuncture need to respond to the question, "Is merely talking with patients a placebo treatment?" Otherwise stated, If no pharmacologic, physical, or procedural intervention is involved, is it a sham treatment? If the opposing authors agree with that statement, then all of psychology and behavioral medicine for pain management is to be discarded. But the authors must then respond to an overwhelming history of carefully conducted scientific studies which have clearly shown that CBT and patient education on pain can alter fMRI findings and improve outcomes in chronic pain.

If the placement of needles is another modality where mindfulness, CBT, and education on painful sensations can occur, then acupuncture's benefit may very well be useful and should be employed as an option in chronic pain. Biofeedback is an example of such an established modality in CBT to help patients develop self-management techniques in chronic pain. Acupuncture, which can be used as a modality to help patients focus on their sensations and ability to manage their pain through pressure points, would be another modality that aids in CBT for pain.

The opposing authors might want to focus on the aspects of acupuncture that make it effective (when it is), such as the manner in which it's done. Physical therapy combined with CBT (i.e. therapists who utilize psychology during sessions) produce better results for longer in more patients than merely modalities (heat, massage) alone. Most acupuncturists I know educate patients and cause them to focus on mindfulness during their sessions. The combination may be a form of CBT that is just as useful as biofeedback, and equally safe.

Setting aside the remarkably poor English – surely no one would use acupuncture to cause pain? What was meant is ‘pain relief’ or ‘to treat pain’, BMJ editor please note – the question is whether doctors should recommend the use of acupuncture.

Doctors are ethically bound to use treatments which benefit patients, taking into account any risks. Ethically, doctors can carry out research into innovative treatments, but the answer to the question posed about whether doctors should recommend acupuncture must be: ‘No, because although consulting with an acupuncturist can have an effect, as Dr Cummings himself points out ( “For those patients who choose it and who respond well, it considerably improves health related quality of life…”), we know how such benefit is achieved – acupuncture is a theatrical placebo.

If it works to relieve pain (the question posed), it should work on a wide variety of patients, not just “those who choose it” and who are already part seduced.

As for doctors recommending acupuncture, it could be said there is nothing unethical about using such a placebo, providing the patient is told that is what it is. But how many patients agreeing to submit to acupuncture do give fully informed consent? And surely, doctors who fail to obtain fully informed consent are acting unethically and might be regarded as quacks.

Acupuncture is one of an array of practices used by camists, most of whom are not doctors registered with the GMC. Dr Cummings has failed to address whether or not doctors should engage in such practices, but rather has avoided that question and sought to answer a different question - seeking to justify acupuncture on the grounds it has a beneficial effect in moderating pain. I do not doubt that the care Dr Cummings gives his patients helps them deal with their pain and makes them feel better. But that attests to his charisma and skills at TLC. The pins and needles have no reproducible worthwhile effect. His reply to the question as posed applies the logical fallacy of a red herring.

Ad hominem is to be avoided, but Dr Cummings seems to have built his career since leaving the RAF on the premise that needling patients has an effect greater than simply caring for them. Perhaps the needles act as a hypnotist might use a swinging pendulum – to induce the response expectances – but the fact remains there is no proven benefit from needling patients.

As for research – has anyone carried out ‘genuine’ acupuncture on a group of anaesthetised patients (for any minor surgery procedure), and compared the outcome to a group of patients told after recovery that they had been needled, when they had not been? Thought not. But if the outcome was identical, the value of the needling process would be disproved – and acupuncturists could stop subscribing to courses, conferences, books and journals describing the meridians (and labeling them, ‘T37; F65…’) – and to providing careers for protagonists. The money saved could be spent on caring.

(Such research would be ethical if both groups of patients were told the nature of the experiment and consented to take part.)

Acupuncture takes its name from the Latin for ‘a needle’ – acus. I would prefer we use the Greek – belone. ‘Belonetherapy’ seems more apt. Doctors should not be involved.

Hrobjartsson and Ernst respond to the combative format of the BMJ ‘Head to Head’ piece by using an adversarial approach. They display the arguments they honed over many years, but fail to properly engage with some important, debatable issues – such as evidence of mechanisms, the concept of ‘medical acupuncture’ , the reliability of the current evidence from systematic reviews, and the logic of placebo and other treatment controls. They may win the case in the eyes of any jury that has preconceived notions such as ‘Acupuncture can’t work, so it doesn’t work’, but regrettably they hardly take the debate forwards in a way that increases understanding.

Like any skilled barrister, they open their case by ridiculing the opposition – ‘irrational and superstitious’, ‘fringe’, ‘implausibility’, ‘alternative’ and ‘theatrical’; they say that even the Chinese, who discovered acupuncture, went through a phase of dismissing its explanations as unscientific. Guess what? so do many thousands of acupuncture practitioners today. They use a strictly rational approach known as ‘Western Medical Acupuncture’ using the nervous system instead of ‘meridians’ - it works just as well! Whole textbooks have been written using the Western approach.

Hrobjartsson and Ernst patronise their opponents. They condescendingly label them as ‘acupuncture enthusiasts’, implying that enthusiasm leads to hyperbole and irrational thought. Actually, many highly rational practitioners who have experience of acupuncture and its benefits for their patients have been forced to conclude that acupuncture works in a manner that is extremely difficult to dismiss as placebo.
When it comes to the nub – whether acupuncture has plausible mechanisms or not – Hrobjartsson and Ernst state: ‘mechanisms … remain opaque’. They do not provide any supporting references, so this remains an ex cathedra statement. But the mechanisms of chronic pain itself also remain opaque. So it is premature to expect acupuncture to supply a single coherent mechanism, though plausible mechanisms certainly exist. Admittedly, the current reviews on acupuncture mechanisms can be quite hard work.[1] The emerging evidence on the effect of acupuncture on neural networks is certainly not easy to digest, but the effort is highly rewarding as a powerful understanding of the complex neural effects of acupuncture begins to unfold. The fundamental ‘default mode’ network is disturbed in chronic pain, and becomes less disturbed over a course of acupuncture,[2] in proportion to the degree of pain relief.[3] The precise meaning of this is unknown, but investigation of neural networks is likely lead to greater understanding of the various contributions of needling itself as well as the other components of acupuncture consultation, such as expectation, touch, and needling sensations. It promises to throw light onto the fascinating observation of progressive relief of chronic pain over repeated acupuncture treatments.

When it comes to the clinical evidence, Hrobjartsson and Ernst have clearly looked at the systematic reviews – though it is arguable that evidence on acupuncture is not really ready for judgement by systematic review. Without (expensive) basic research into the neural effects of needling, the treatments used in some trials may be less than optimally effective, and the ‘placebo’ controls used could well be active. Even worse, variations in treatment approach often mean that only small groups of studies can be combined, reducing power and biasing towards a negative result. This limitation to the evidence should not be ignored. Interestingly, systematic reviews of acupuncture for a given topic can become more positive when repeated over time as more and better quality evidence accumulates. [4,5]

The evidence comparing acupuncture with other treatments often shows really worthwhile, lasting benefits. So patients might think it challenging for Hrobjartsson and Ernst to dismiss these benefits as ‘possibly due to bias’ without providing (as Cummings asks) some supposed mechanisms for this bias.

Hrobjartsson and Ernst’s interpretation of the evidence is that acupuncture is superior to placebo, but that the difference is not clinically significant. But they fail to address important debates, for example about the enhanced placebo response to acupuncture (expounded by Cummings); the evidence from meta-analysis that no other available conservative treatment is more effective for knee osteoarthritis pain than acupuncture [6]; and the appropriateness of judging clinical significance by comparing acupuncture with a treatment (placebo needling) that is not actually available.

In practice, many physiotherapists find that adding acupuncture provides just that additional degree of pain relief that allows patients to resume their highly beneficial exercise; and GPs welcome having something to offer their patients with knee pain other than long-term drugs. Desktop researchers need to find a way to take some account of these anecdotal clinical experience.

The scientific community have somewhat delegated the responsibility for investigating the complex issues involved in acupuncture to experts such as Hrobjartsson and Ernst. Are they justified in doing so? Those who have witnessed the benefits of acupuncture may feel that this article does not provide much new insight into the medical (neurological) acupuncture approach, or into the interpretation of trial evidence, or the evidence for acupuncture mechanisms, or possible mechanisms underlying the claimed ‘bias’ in comparing acupuncture with other treatments.

Acupuncture is more than just needles; the cover is just being lifted on likely powerful effects deep within nervous system; if doctors stop recommending acupuncture for pain, it is a significant loss for their patients.

Competing interests:
I am retired from acupuncture practice and research, but declare a competing interest in this debate because I am convinced I have witnessed clinical improvements beyond placebo – as well as those due to placebo; I have worked with two of the three authors in this Head to Head; and I am Associate Editor of Acupuncture in Medicine

I have been practising acupuncture for 30 years, initially learning in China , while living in Hong Kong.
I also learnt to use it in dental work , doing fillings and tooth extractions successfully under acupuncture anaesthesia, as local drug anaesthesia was more expensive
I also do some steroid injections in both my medical posts,( where the evidence base is inconclusive with small numbers and lack of diagnostic criteria), as it appears to give short term pain relief.
Short term benefit only has been found in shoulder pain,(Buchbinder et al) with a RCT showing no benefits at 12 weeks. Likewise with tennis elbow ,some reduction at 4 weeks with no effectiveness long term in a large multicentre study.
I attended a lecture by a senior physiotherapist 2 years ago where again a conclusive evidence base appears to be lacking.
It is a shame that the focus has been on sham acupuncture used as a placebo in acupuncture trials when other modalities could be used .
I find acupuncture greatly benefits my work, eg in needling deep contracted muscles around joints or treating a severe headache and feel its benefits should be more widely known.

For many people, pain control remains unsatisfactory. Drug therapy is the usual response but mild remedies are often ineffectual, non-steroidal anti-inflammatory agents have their problems and codeine can be difficult to tolerate. The side-effects of opioids are well documented and can lead to addiction. Promising opoid related drugs have their day, are srongly promoted by industry and others, until their limitations are realised. This article provided a good brief review of acupuncture and its limitations.

Thought Field Therapy and related techniques have been described as "acupuncture without needles" and have been used to treat pain, either alone or in combination with pharmacological treatments. There are several proposed mechanisms of action, with some supportive evidence, some more plausible than others. Other touch therapies are likely to have a similar mechanism. Unfortunately, despite several small research studies, the evidence for effectiveness is weaker than for acupuncture. However, these techniques have little or no side-effects and can be delivered cheaply. Patients can be self-taught in group sessions although individual follow-up may sometimes be needed.

Unfortunately, there are not the resources to investigate these promising therapies adequately, in contrast to the funds available from the pharmacological industry to further their own commercial interests. Further studies of Thought Field Therapy and related techniques to help patients with pain who are not adequately helped by current treatments are needed.

Competing interests:
Chairman of Thought Field Therapy Foundation UK Ltd, a charity committed to poromoting research into Thought Field Therapy and supporting its humanitarian use, especially for post-conflict psychological trauma.

As Mike Cummings points out, so-called sham acupuncture is not an inert placebo and therefore true placebo-controlled RCTs of acupuncture are difficult to perform. In this respect acupuncture is similar to other types of manual therapy, such as physiotherapy and osteopathy, which are also difficult to find satisfactory control procedures for.

It is easy to show that acupuncture is an effective form of treatment in comparison to usual care in a number of conditions, but disentangling the various elements that are involved in a typical acupuncture treatment session is problematic. This will, of course, include the placebo response, but we shouldn't forget that this response is itself a central nervous system phenomenon!

Acupuncture is best thought of as a form of sensory stimulation. Emphasis on "acupuncture points" is only relevant to traditional acupuncture. It is possible to perform needling therapeutically without using classic points. I think myself that where you needle is often less important than how you needle. A good illustration of this, in a non-pain context, comes from Xu and colleagues (CMAJ 2013; 185(6): 473­478 - doi: 10.1503/cmaj.121108).

In this RCT patients with Bell's palsy received prednisolone plus either acupuncture using gentle stimulation or stronger acupuncture which induced the characteristic acupuncture sensation. Six months after treatment the degree of recovery was assessed blindly by three neurologists who viewed video images of the patients performing standard facial expressions. Those who had received the stronger treatment had a significantly better outcome in respect of facial function, disability, and quality of life.

This trial is significant because it used an objective end point unrelated to the patients' subjective assessment of the effectiveness of treatment. As John Fletcher remarks in his accompanying editorial, "it is difficult to see how the differences seen could not be due to real differences in facial nerve recovery".

Competing interests:
I am a member of the British Medical Acupuncture Society. I have practised and taught modern acupuncture (Western medical acupuncture) for many years.

The topic is "should doctors recommend acupuncture for pain?"[1]. I feel a bit sorry because this topic is rarely discussed in top Chinese journals.

Acupuncture is the treasure of Chinese traditional medicine. However, what are the prospects of acupuncture nowadays? In China, a hospital or clinic has either the Chinese medicine side of things or the conventional western-style side of things. Some hospitals combine care from western and Chinese resources for a given patient. Acupuncture is to some extent used in China.

What are the prospects of acupuncture in future? Maybe, you can get to know something from the rapid responses of this topic "should doctors recommend acupuncture for pain?". Thanks for such a good topic. Thanks to The BMJ.

Both sides of the debate present the benefit of acupuncture as ‘small’. However, Cummings insists that this effect is ‘highly statistically significant’, while Hróbjartsson and Ernst call it ‘clinically irrelevant’ (1,2). I would like to argue, especially in the context of chronic pain, that this effect has a role in treatment and acupuncture should be recommended.

Chronic pain affects a significant proportion of the population (3). It is a reality that Western-style medicine is not especially effective at treating chronic pain. The mainstay of treatment till now has been long term analgesic medication, especially using opioids, which in itself is problematic. Evidence for their long-term efficacy is lacking (4,5) and dependence is common. The U.S.A. is currently experiencing an ‘opioid crisis’ where overdose deaths using prescription opioids has quintupled since 1999 so that in 2016 forty-six people died every day from overdoses involving prescription opioids (6,7). Also, in Denmark, where opioid prescription has increased by 600% over the last 20 years (8), prevalence of chronic pain remains unchanged (9).

Many patients experience chronic pain that is refractory to pharmacological treatments (10). These are complex patients, who have tried many drugs and for whom there has been little or no improvement in their pain. Effectively, these patients have reached the limits of modern medical treatment. Acupuncture may provide some (if only little) relief for these patients and I would argue that any improvement for this group is worthwhile. This is especially the case if it improves the patients’ function and allows them to reduce the doses of their medication (especially with opiates and steroids).

Psychological factors are important in chronic pain and interventions specifically targeting these are indicated (10,11). Psychological therapy such as cognitive behaviour therapy (CBT) has been shown to have a small beneficial effect in the treatment of chronic pain (12–14). Though acupuncturists are not performing CBT during their appointments, they have much longer to discuss patients’ problems, both physical and psychological. In an hour’s appointment they are able to explore in a professional and caring manner the patients’ ideas, concerns and expectations more comprehensively than in a ten minute GP appointment. During consultations acupuncturists discuss patients’ problems and offer lifestyle advice. Of course they place needles, but this is part of a holistic therapeutic experience. In this respect acupuncturists are both therapists and counsellors, which is why it is unfair to brand them with the term ‘theatrical placebo’. Part of the consultation’s purpose is to discuss all the patient’s problems so by definition is not a ‘placebo’ as its declared goal is psychological benefit. Regardless of these semantics there is evidence that ‘sham acupuncture’ improves quality of life, even outperforming usual care in chronic pain (15).

The fact that we do not know how acupuncture works should not preclude its use. There are countless examples of therapies the medical profession started using before fully understanding how they worked mechanistically (penicillin is an obvious example). This would be an indefensible stand-point if the trial therapy turned out to be harmful, but adverse effects in the hands of trained acupuncturists are rare, especially pneumothoraces. In a trial of 97, 733 patients undergoing acupuncture (with over 760 000 sessions), Melchart reported only two such events and concluded that ‘serious adverse effects of acupuncture seem to be true rarities’ (16).

Acupuncturists are trained and regulated professionals. It takes three years to qualify in the UK and though currently self-regulated the British Acupuncture council (BAcC) is campaigning for statutory regulation. BAcC is accredited by the Professional Standards Authority and acupuncture was described as ‘robustly self-regulated’ by the Secretary of State in 2011 (17). We are no longer in the Victorian era- acupuncturists are not charlatans. They uphold high standards of practice, especially in terms of hygiene using aseptic non-touch technique and safe sharps disposal as would be expected in any clinical setting. In addition, acupuncturists do not advocate acupuncture over mainstream medicine, but as a complement for the treatment of certain specific conditions.

To conclude, I would agree that the effect of acupuncture is likely small and the evidence is of variable quality. I don’t think acupuncture for chronic pain would be cost effective and for these reasons I would not advocate its routine provision on the NHS. However, I think medical professionals are justified in telling patients with chronic pain that there is evidence that acupuncture may make a small improvement to their symptoms and their function. This should not replace the pharmacological therapy they are taking, but should complement it and if this means that they are able to reduce the dose of their medication this should be encouraged (especially where opioids are concerned). The additional caveat is that they will have to pay for therapy themselves. They should also be reassured that adverse effects of acupuncture are vanishingly rare.

What’s notable about this discussion is a total lack of reference to the other available treatment options for pain that doctors decide amongst and how acupuncture compares in terms of efficacy, effectiveness, safety and cost-effectiveness. Surely this is the only reasonable starting point for any intelligent discussion about how healthcare resources best be utilized.

Continuing to discuss acupuncture in an artificial vacuum, as Ernst and Hrobjartsson have done, there are a few things to note. First, the small effect size of acupuncture over sham needling for pain both demonstrates specific effects of acupuncture and simultaneously, is a completely irrelevant comparison to determine ‘clinical effects.’[1] Doctors and patients are not choosing between acupuncture and sham acupuncture needling control; they are choosing between acupuncture, paracetomol, NSAIDs, opioids, surgery, off-label, poorly tolerated, experimental medication in the case of migraines and fibromyalgia, and physiotherapy, all of which are limited in their evidence for treating pain. Sham controlled acupuncture trials merely assess two different types of acupuncture needling. Both are often superior to conventional care in terms of pain reduction and improved quality of life, with the highest-quality evidence demonstrating a statistically significant benefit of acupuncture over sham needling.[2]

If we look at sham controlled studies of orthopedic surgery, we find no difference between real surgery and fake surgery at all.[3] Clearly surgery and acupuncture have similar methodological challenges to being studied using the double-blind RCT design held as the gold-standard for pharmaceuticals. If lack of practitioner blinding is such a powerful force, this should have a much stronger effect in the case of surgery trials and yet surgery fails to demonstrate efficacy. It seems odd to argue against something with at least small specific effects and large non-specific effects (in other words, large proven clinical effects in helping patients reduce their pain) when one utilized alternative lacks evidence of efficacy and is invasive and expensive to boot.

If the authors’ reading of the acupuncture mechanism literature stops at the gate control theory, I’m confused as to why they feel qualified to comment as subject experts. Specific mechanisms for acupuncture in pain control are well-documented, including peripheral effects through purinergic signalling and nitric oxide, spinal reflexes, modulation of endogenous analgesic biochemicals, improved functional connectivity in the brain, modulation of parasympathetic activity and modulation of inflammatory signaling.[4]

Of course, the ability to articulate how a treatment works has zero relevance on clinical effectiveness. On the other hand, a recent review in this journal on the harms of paracetamol notes that the ‘mechanism of paracetamol’s analgesic action remains largely unknown.’ [5]

This comes after another recent review of paracetamol for spinal pain and osteoarthritis, also published in this journal, that finds that “paracetamol is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis.”[6] In short, paracetamol is widely prescribed, increases the risk heart attack, stroke, kidney damage, GI bleeding and death, and we don’t know how it works which is moot because it doesn’t work anyway. As such, arguing against acupuncture, which has greater demonstrated efficacy and safety, is not an evidence-based perspective.

Another mainstay of pain treatment in the NHS are NSAIDs. These drugs suffer from a paucity of long-term studies but are frequently prescribed indefinitely, despite serious risks. A recent review looking at over 400,000 patients, also published in this journal, found that “All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction” when taken for as little as one week.[7] A now out-dated and absurdly conservative estimate shows that the adverse effects of NSAIDs costs the NHS a median estimate of £251 million pounds a year[8].

Of course, the harms caused by NSAID and paracetamol pale in comparison to those of opioids, which are addictive, frequently debilitating and often lethal (in the UK, deaths related to prescription opioids doubled between 2005 and 2009[9]), which is why until a successful albeit illegal marketing campaign by their manufacturer in the 1990’s, oral opioids were only available as end-of life pain management for terminal cancer patients. As such, it’s interesting to note that the only study ever performed on long-term effectiveness of opioids for pain-relief found that those taking opioids were actually in more pain than controls.[10] Recommending against acupuncture to treat pain directly increases the usage of these dangerous and ineffective drugs.

Compared to physiotherapy, acupuncture has a much stronger evidence base. As one point of reference, there are over 10,000 trials on Cochrane’s Central Register for acupuncture compared to under 7,000 for physio. With this in mind, it’s interesting to note that physios frequently add acupuncture to their practice (the UK’s Acupuncture Association of Chartered Physiotherapists boasts over 6,000 members), often after very minimal training, contrary to World Health Organisation safety recommendations. It’s difficult to reconcile why physios would increasingly start using acupuncture if it didn’t work. Are you suggesting that physiotherapy is so ineffective that thousands of physios are offering a placebo to their patients instead?

Any discussion about which treatments should be recommended for pain should be based on a comparison of the benefits versus the harms of available treatments. This is self-evident. Such an approach, no matter how you slice the evidence, leaves acupuncture amongst first-line treatment options for pain, if not a clear winner. If Hrobjartsson and Ernst insist on banging the disproven placebo drum despite repeated demonstration of specific effects, clinical superiority over treatments that themselves are superior to placebo and despite the scientific community’s clear understanding of specific mechanisms of how acupuncture is able to achieve these results, then the discussion we should be having is not about the ethics of recommending placebos. Rather the discussion would need to be about the ethics of recommending treatments that fail to outperform or are inferior to a treatment that you claim is s placebo, all while exposing patients to avoidable harm. That’s the only logically consistent reading of your suggested interpretation. So let’s have a discussion about the ethics of that.

In the interest of patients and the responsible provision of healthcare resources, I sincerely invite the authors to explain: if not acupuncture for pain, then what do they recommend instead and based on what evidence? If they continue to argue against acupuncture on theoretical grounds but are not aware of options with stronger evidence of effectiveness or safety, then the medical community should continue to ignore their complaints.